Wednesday, June 1, 2016

From precision medicine to community vital signs

Last fall, I expressed concerns that the federal government's push to accelerate developments in "precision medicine" will draw attention and funding away from population health initiatives that could make a positive difference here and now. I still feel that way, particularly in light of preliminary CDC findings suggesting that the age-adjusted U.S. mortality rate rose last year for the first time since 2005. The bad news affects different groups of Americans in different ways. A previous analysis led to news stories asking, what's going on with middle-aged white Americans in rural areas? The next question is, what can health care or social services do to help them as well as traditionally disadvantaged populations?

Family doctors like me are generally comfortable with screening patients for physical conditions such as high blood pressure and cholesterol, infectious diseases, and cancer. Unless patients volunteer this information, I am far less adept at asking about "social" conditions such as alcohol misuse and intimate partner violence, even though the U.S. Preventive Services Task Force has concluded that both of these screenings can improve health. The prospect of asking my patients if they experience other negative social determinants, such as financial insecurity, housing insecurity, joblessness, and childcare challenges is even more intimidating.

But that's exactly what three family medicine clinics in Albuquerque, New Mexico did with an 11-question instrument called WellRx. As researchers reported in the May/June issue of the Journal of the American Board of Family Medicine, these clinics administered WellRx to more than three thousand patients over a 90-day pilot period and found that 46% screened positive for at least one area of social need, with most having multiple needs. Critically, every patient with a positive WellRx screen was referred to a community health worker (CHW) trained to address identified needs:

Services offered by CHWs included helping patients to access resources like food banks and to fill out job applications, accompanying patients to apply for food stamps, conducting home visits, or arranging family meetings with the health care team. A patient's level of need dictated the intensity and duration of the CHW's interaction with that patient—usually 1 contact a month and usually for less than 3 months.

Although the researchers reported that their university hospital was convinced enough by this pilot study to implement screening for social needs in all 7 of its primary care clinics, it remains to be seen if these screenings and CHW referrals will lead to health benefits. Even though 11 questions doesn't seem like a lot, given how many (less useful) administrative tasks are already required of primary care, many practices may be unable to routinely collect this information. One possible alternative is leveraging big data, argued Dr. Lauren Hughes and colleagues in the same issue of JABFM. Rather than collecting information about social determinants from patients one by one, they advocated "linking aggregated population health data" with patients' home addresses in electronic health records to provide physicians with an easily accessible set of community vital signs.

Either approach to data collection about social needs faces challenges and skepticism from physicians who aren't yet convinced of its utility. In response to an AAFP News article about community vital signs, one physician commented, "Fantastic! This is just what underworked and overpaid family physicians need- a massive data dump into their EMRs of public health info that they are expected, coerced, and eventually forced to analyze and act upon." Another wrote, "I can imagine it might be interesting to have some of this data occasionally but practically it would have essentially zero impact on a physician interaction with a patient." Zero impact? I have to disagree. Although the jury is out on the potential benefits of clinically-enabled community health interventions, my feeling is that they will be a lot more impressive than those of precision medicine.